Your Questions
Your Questions
Q: Dr. Eppley, I am very interested in the tear drop breast augmentation procedure. I am currently a small B and would like a small change to maybe a full C. I really want a natural look and a small implant so that my breasts still look natural and do not stick off my chest or look high up, so i am interested in the teardrop shape implant.
I also am interested in a chin reduction since mine is very long and prominent and protrudes significantly when I smile. I would like it to be shorter and narrower/ pointier. Another thing is that my face is rather narrow and long and I desire a rounder face and more full look, what procedures could help with this? I want my cheeks to be wider in diameter if that makes sense? thanks!
A: While you have mentioned tear drop implants for a natural look in breast augmentation, be aware that the same effect can likely be achieved using low profile round implants which often create the same look. In the upright position tear drop and low profile round implants have been shown to look the same. I mention only because the cost of tear drop breast augmentation is higher.
Otherwise a submental approach to your chin reduction is the best method to address both bone and soft tissue excesses.
The one procedure that is most effective at helping widen a face are cheeks implants. But not just any cheek implant will create that effect. It takes a special design cheek implant that specifically focuses on adding width back along the zygomatic arch.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, i had a few quick questions about Medpor chin implant removal in advance so that I can speak with you with a clearer understanding of surgical possibilities next week.
1) If an implant is placed via an intra-oral incision, can it still be accessed via a sub-mental one?
2) Instead of removing a Medpor implant and replacing it with a different shape or size, can it be edited / cut down whilst still attached to the chin?
3) In my case my lip function is perfect. However the position of the lip is not correct; it feels like my lip is being pulled downwards by the weight of my mentalis muscle which (i believe) was not reattached successfully. Can the reattachment be made without further risk to the muscle-lip function?
Of course our conference call should give you a better visual idea of my situation and whether or not i have correctly identified the problems i am noticing.
I look forward to your thoughts.
A: In answer to your Medpor chin implant removal questions:
1) A chin implant that was placed intraorally can be subsequently accessed from a submental incision.
2) It is almost never a good idea to modify a chin implant in place as the amount and type of modification is very restrictive…and thus limits what can be effectively done.
3) I doubt very highly that the mentalis muscle was not reattached properly as there is only one way to do it…it is either done or it isn’t. It is important to remember that a chin implant displaces the muscle in an unnatural way forward. Your anatomy was not made to have an implant behind it. When this natural anatomy is changed and the muscle is dragged up over an implant, particularly one that gets a lot of soft tissue adherence, the risk is that it may feel stuck or being pulled down. That is why it feels the way it does, it has nothing to do with the muscle per se and messing with the muscle is going to create more problems not less.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I talked to my surgeon and he explained some of the difficulties that may come of infraorbital implant removal. You see I had it done together with a SOOF lift and lower eyelid retraction surgery and so removing the implant might compromise the support of the lower eyelid area. I wanted to ask some tentative questions in case I go ahead with removal:
-How would you handle the risk of undoing the lower eyelid surgery I’ve had done and prevent any adverse effects that might require further surgery in the future?
-Is my surgical case very uncommon or something you have experienced before?
-If I am unlikely to return completely to my previous look, what type of change is reasonable to expect, or perhaps that’s impossible to say?
At one month after surgery there is still some swelling but I believe I am correct that the sharp edges I see below my eyes are indeed the implant as it’s quite palpable. Just to be sure though I’ve attached two recent pictures and two of my face before surgery if you have the time perhaps you could take a quick look and tell me if there is any hope at all that this issue will resolve itself?
You correctly assumed the incision method and the size of the implants should be relatively small but they appear quite prominent, maybe because of the thin skin in the area. I forgot to mention that these are “extended infra-orbital implants” so they are longer than is usual which I now think was a mistake.
A: Thank you for sending your pictures. The basic concept is that you are going to have to undo everything that was done to do infraorbital implant removal. In addition there is little guarantee that you will return to your preoperative eyelid shape state.
These two concepts should give you great pause at this early point after surgery in having a reversal/removal procedure. Any implant edges that you feel now with time will not likely become less. They over time indeed may become more prominent. But no one can predict how you will feel about it months from now…which is the time one should allow for full healing to occur.
The ‘mistake’ that is often made in infraorbital implants is using preformed implants. The tissues are too thin and the implants are standard shapes, a set up for implant edge capability and potential visibility. This is what I almost always use custom implants or ePTFE sheeting which allows for very feathered implant edges and a better blending into the surrounding bone margins.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We spoke several months ago about my slipped rib and the possibility of having rib removal surgery for it. I’ve tried to manage things conservatively but my pain has not improved. In weighing the risks-benefits of an eleventh and twelfth rib resection, one of my concerns is the risk of a flank hernia. As you know, there is very little data on this in the medical literature. Most of what I’ve been able to dig up is in the context of rib resection to facilitate kidney removal. I would imagine that based on your extensive experience resecting ribs, you probably have more data than anyone on the potential risk of a flank hernia. In short, with the obvious disclaimer that you’re not giving me any formal medical advice, I would appreciate hearing your thoughts on the risk of a potential flank hernia from a resection of the eleventh and twelfth ribs. Thanks again for all your help. I really appreciate the time you’ve taken to answer my questions.
A: The simple answer to your rib resection question is that I have never seen such a complication or would I ever anticipate one. With preservation of the medial periosteal layer I can not imagine this occurring. This is quite different than opening up the peritoneal space for kidney removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came to your office back in August of last year. I had a temporal artery ligation on the right side of my head. The procedure went very well and is still holding up fine. I am planning to come back in the spring or summer of this year to have the left side done. My question for you is that I have some early stage pre-cancer spots on my head. This is from the result of being bald and exposed to the sun for most of my life. My Dermatologist has prescribed 5% Fluorouracil Cream to spread on my head twice a day for two weeks. This should help or take care of that problem. I just want to make sure that this cream will not affect the ligations when the outer skin peels off to replace the new skin. Thank You in advance for answering my question and I look forward to visiting your office again. Thanks.
A: Thanks for the followup and glad to hear that a good result has been obtained and is being maintained. 5FU is a strong chemical peeling agent that is commonly used in the treatment of superficial skin cancers. Its use will not interfere with the performance results obtained from a temporal artery ligation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it has been a while since I last spoke with you and I have been thinking more about the paranasal implants. In the photo morphs you sent me, we had adjusted the degree of projection to be a little bit less than the first morph sent a while back. In the current photo morph how much thickness of the implant would you estimate using? (<5 mm). The first picture is the morph of my face, the second an example of paranasal augmentation with cartilage I found in a paper, and the third is a patient review from a Korean plastic surgery site.
I have seen quite a few results from Korea on this procedure, but I feel that there is too much augmentation in these procedures, leading to an unnatural upper lip appearance. Before going for implants can an adequate saline injection or temporary filler give me a good simulation of how the implants might behave on my face?
If not, do you happen to know of any other publications or available data/photos on paranasal implant results?
Thank you for your time and advice.
A: When it comes to any form of facial augmentation, it is not an exact science. There is no way currently to know precisely what effect any degree of augmentation could create or how a patient will feel about the degree of change they have experienced. The only thing I know for sure about paranasal augmentation is that anything less than 3mms would be too small and anything bigger than 7 or 8mm would probably be considered too much. But how to pick an amount augmentation within this range is anyone’s guess.
Certainly injectable fillers are an accepted temporary approach for a paranasal implants augmentation trial. They do not have the same push as an implant and do not create the exact same look, but they are still reasonable to try. But I am not sure they really give a good ‘implant test’ response.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some concerns regarding my head shape. To be specific, I have some abnormalities that are isolated to the top of the back of my head. I have one quite big indentation, probably caused by something hitting me to the head when I was younger, which also has caused the skin surrounding the indentation area to be a little lumpy. I believe I have a head shape similar to the “Skull reshaping 10” pictures from your photo gallery. I believe the only way to fix it is by adding what you call bone cement in the indentation. My questions to you are:
– Do you think this indentation is fixable? And from the little I have explained above, do you think fixing the indentation also would fix the lumpyness around that area?
– How much time is needed for a procedure like this? Are we talking a week or more for recovery?
– What are the risks when adding bone cement to my existing bone structure?
– Will putting bone cement into my body be of any hindrance when it comes to physical activity etc?
I hope you can answer all my questions, and I do hope this is something that could work for me, as it has been something that I constantly worry about.
A: To best answer your skull reshaping questions about what can be done with your skull shape concerns, I would need to see some pictures of your head. By your description the best way to effectively treat it would be a custom skull implant made from a 3D CT scan. This procedures the best contour result while avoiding any edge contour issues of the implant-bone interface. This is a procedure in which you could return home in a few days after the procedure. Rather than being a hindrance to any physical activity, such an implant actually increases the protection of the skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Two questions about buttock implant removal:
1.Do you remove the capsule? I would like to try fat grafting in the future to try to achieve a more normal appearance. I understand if the capsule is not removed or if it does not close completely the injected fat can die if it is injected into an empty pocket. Would you agree? Or is it better to leave the pocket for some “padding”?
2. Can fat grafting lift up a sagging buttock after implant removal or do you need something more solid like an implant?
Thanks
A: In answer to your buttock implant removal questions:
1) It is not necessary to completely remove the capsule and in trying to do so can be source of postoperative hematoma and would mandate the use of drains. The capsule will naturally undergo a lot of resorption once the implant is removed since there is no purpose for it any longer. It is not true that if fat is injected into it, it will die. In fact some surgeon espouse the opposite….injecting fat into a capsular space enhances its survival. But this is is really an irrelevant discussion sine the you might be injecting fat will be long after most of the capsule is gone.
2) Fat grafting will not lift up a sagging buttock. It takes a strong push from a solid implant to have that effect unless one injects a tremendous amount of fat…which you don’t have to harvest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing to ask about the paranasal implants. I have been doing research on this type of facial implant for a while. I have some questions.
- One is what is the material for the implants?
- Will it affect my facial expressions?
- How long will the implants last?
- Will they move around?
Thank you for your help!
A: In answer to your questions about this type of midface implant I can provide the following answers:
1) Paranasal implants are composed of either a solid silicone or an ePTFE material. The silicone ones are preformed. The ePTFE ones are hand carved at the time of surgery to the desired dimensions. There are advantages to each type of material but both can work well.
2) The implants initially will make your smile feel a little stiff but usually resolves by 6 weeks or so after surgery. There should not be any long-term facial movement limitations as long as the implants are not too big.
3) The implants are permanent and their shape and structure can never change or degrade over time. The materials used are non-biodegradable and non-reactive.
4) Paranasal implants will not move or become displaced as they are secured in place by small micro screws.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Dr Eppley, five years ago I received illegal silicone buttock injections once and I believe it is catching up with me now that I’ve become pregnant. I lost a ton of weight in the beginning of my pregnancy from being sick and was in the bed for months. I started noticing 5-6 hard lump areas in my butt and thigh areas and when I visited my family doctor he couldn’t understand what it was. They did a tissue ultrasound and didn’t see anything so they just prescribed me an antibiotic and said since I hadn’t had a fever or any pain, it should be ok. My OB however said he had seen this in pregnant women before and said not to worry about the antibiotic, but it would eventually go away (I don’t think so, it’s been months). I didn’t tell them about the injections out of embarrassment but I just need to know if you think this maybe the issue, and I so if I could get a consultation from you and possibly some insight on what to do?
Thank you!
A: Such buttock bumps as you have desired are undoubtably tissues reactions from the prior silicone injections. Why they have chosen to develop during your pregnancy I can not say. Perhaps the change in your hormonal levels from the pregnancy has ‘stirred them up’ so to speak. During your pregnancy no treatment for them can be done. But in a non-pregnancy state and if they became more symptomatic (continues to get bigger or become red), the treatment for them would be liposuction with fat injections. Antibiotics are of no benefit unless the areas became red. It will be interesting to see if they lessen once you deliver and your hormonal levels drop back to normal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What bothers me most is my side facial profile. My nose looks big because my teeth were pushed back so far with braces as a kid. I realize it was the common practice decades ago to pull teeth instead of widening the arch and pulling my lower jaw forward. I know it’s possible for a maxillofacial/craniofacial surgeon to slide the upper jaw and lower jaws forward but since my bite is actually good, I have had a hard time finding a surgeon in Oklahoma to do it. They don’t want to mess up my teeth but I am willing to do braces or Invisalign if possible and get teeth implants if needed to replace the ones that were pulled out when I was a kid. Basically I’d like to make my jaw more defined and more pronounced mandible.
A: Since you have identified your major concerns, a perceived midface deficiency, I can make the following comments:
1) With a stable and orthodontically corrected bite, your only option is a bimaxillary advancement surgery. (both and lower jaws moving forward together since the bite must remain unchanged) While this can certainly be done (and your chin position would actually benefit by it as well), this does require the application of braces immediately before and for a short time after surgery to correct any potential minor changes in one’s bite.
2) I would agree that your fundamental facial issue is the overall upper and lower jaw horizontal deficiency. A bimaxillary advancement certainly addresses this fundamental problem. It is the harder road to take so to speak but may be worth it at your age if one is so motivated.
3) Be aware that a bimaxillary advancement will not make your look smaller as the entire base of the nose is carried forward along with the maxillary advancement. The only way the nose can look smaller is by not moving its base and changing everything around it. (see #4 below)
4) In fairness and to give you the complete picture, there is also completely alternative treatment strategy which includes paranasal-maxillary augmentation, reductive rhinoplasty and chin augmentation. This is a different way to achieve many of the same results without going through a major maxillofacial osteotomy procedure and its potential associated morbidity. This will also do what a bimaxillary advancement surgery can’t do…make your nose look smaller.
5) These two approaches to your facial concerns represent a diametric and completely opposite treatment strategy…correct the bony foundation or an augmentative camouflage approach. Neither one is right or wrong, each has their own distinct advantages and disadvantages. Understanding what they are is the key to making the best treatment choice for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking treatment for an apparent linear scleroderma. I am delighted to know there is something that can be done to restore or improve my facial appearance. Is it common for a discoloration of coupe de sabre that was a relatively small discoloration to enlarge and become indented with age? In fact, I was always told I had a birthmark on my forehead! I was shocked when I came across pictures of people with this condition and even more so to see the changes I was experiencing were similar to some of the milder pictures of those with the condition. This “thing” seems to have taken on a life of its own!
A: While I would have to see pictures of it, everything you are describing is consistent with craniofacial linear scleroderma. This craniofacial condition is largely an unknown entity as why it occurs. While usually developing later in children or teens, I have seen cases that did not emerge until adulthood.
While the traditional approach is to wait and have the soft tissue atrophy burn itself out, I prefer to to treat it with fat injections during the active phase in an effort to stop its progression as well as treat the soft tissue defects. This may require more than one session of injectable fat grafting.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in having male facial sculpting through buccal fat removal and cheek implants. However I’m a bit unsure about the jawline area as whether I should get just liposuction or submentoplasty or custom mandibular implants. I’m aiming for a more chiseled jawline and masculine look. I’ve attached a stock image of the look I’m looking to achieve.
I’ve had a consultation in Europe and the doctor recommended buccal fat removal, zygoma bone grafts for the cheeks and liposuction for the jaw. However I’m unsatisfied with this recommendation.
I’ve attached my images from side front and 45 degree angle, I wanted your opinion on what procedures you would recommend.
A: In looking at your face as well as what your male facial sculpting goals are, I can make the following comments:
1) Your ideal facial reshaping goals, in terms of a chiseled jawline like the picture you have shown, are not realistic. You can never take your face and make it look like that picture. You simply have a much different face that is thicker and fuller throughout the entire face. While improvements are possible with your face, that type of change is too much to expect no matter what procedures are done.
2) Maximal defatting is needed including buccal lipectomies, personal mound liposuction and neck liposuction.
3) Cheek implants that have a high angular design that go back along the zygomatic arch are needed. (bone grafts are not going to be effective)
4) While your beard makes it difficult to assess your jawline, it appears that your chin and jawline needs some vertical length and well as some width. Only a custom jawline implant can create that effect. Liposuction can never create a bony augmentation look and is a flawed approach to it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in waistline reduction by rib removal. Here are some selfies and staged shots of my waistline. In my professional pictures of course the illusion is altered with posing and editing to create more curve but Ive always worked at it. I was drawn to you and how you spoke on the Doctors show with the model Pixie. I’m an entertainer/model and still going strong into my forties. I’ve always been curious about whether Raquel Welsh had rib removal but never the less I am a student of improving what I can. My life’s ambition is to be one of the sexiest women in the world and to stand up for aging women to be considered still desirable and most importantly feel desirable.
A: Thank you for sending all of your pictures. Your current waistline is a fairly standard one from someone seeking surgical waistline reduction. Such a typical patient is in good shape and would have an acceptable waistline by most of society’s standards but such a patient seeks a higher goal than what weight loss, exercise, liposuction and even genetics can do. The last anatomic barrier to a smaller waistline is the free floating ribs, although I have developed the additional techniques of wedge LD muscle resection and more aggressive flank liposuction with it to ensure that all that can be done has been done to achieve the maximal waistline reduction effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have developed a buttock implant incision opening. I have been putting antibiotic ointment on my buttock incision and washing it with Hibacleanse but, a few times when I sat down, lots of fluid came out of the incision. (clear pinkish yelllowish no bad odor or anything) I have to use Maxipads to soak up (a few, two fully soiled) I just wanted to make sure its normal. Also is there another type of ointment you can prescribe that will be stronger in helping the incision heal and close? That would be great. Looking forward to hearing from you, I am pasting a photo in this email of the incision as well.
A: Thank you for your buttock implant followup. It is clear that such fluid output represents a seroma. (fluid buildup in the implant pocket) Having one central infragluteal incision makes it impossible to know whether this is coming from just one or both implant sides. While I would obviously prefer not to have such a fluid output, it is always better that such fluid comes out rather than stays in. I would agree that this seroma fluid does not represent an infection, just a typical serous fluid collection that often develops initially around implants.
As long as this fluid continues to come out, it does not matter what topical treatment you use as it is really irrelevant. The incision is not going to go on to fully heal until this fluid egress ceases. There is nothing you can do for making the fluid output cease, it is just something that has to run its course. Once the fluid output is less or nonexistent, the topical treatment of choice is going to be Silvadene. This will help the wound edges heal in as well as provide an antibiotic effect. This is far more powerful than the antibiotic ointment you are using now. That is something I would like to start as soon as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about my upcoming custom forehead implant surgery.
1. Is it possible the implant can shift?
2. Can you take me through the surgical procedure and describe how the implant(s) will be placed? What materials are being used? How big are the incisions?
3. Will I still feel sensation in my forehead and will it effect my ability to show facial expressions?
4. How long before the “final” results show and I look “normal” again?
A: In answer to your custom forehead implant questions:
1) The forehead implant can not shift for a variety of design and fixation reasons.
2) The bets way to understand the incision and how the implant is placed is go to my website, www.exploreplasticsurgery.com and search under Male Custom Forehead Implant and must look at the pictures I posted one this case from last week.
3) Initially your forehead and the front parti of your scalp will the numb but that feeling will return in the months after surgery. Initially the forehead movement will be stiff but its full range of movement/expressions will return quicker than that of the lost feeling.
4) It actually takes a good 6 to 8 weeks to see the final result but you will look non-surgical in public by about 2 weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had a liposuction surgery three years ago for my lateral thigh. After that I had a fat injection (six month ago) because of the indentation that occurred from the liposuction. After secondary fat injection, the seroma formed. However I had it drained it seven times but it keeps coming back. Last week my plastic surgeon placed a drainage tube, cleaned and freshened my iwound and I wore compression garments. But unfortunately the seroma does not stop . Please help me.
A: While I don’t know the size of your thigh defect, your history suggests an encapsulated seroma cavity. What this means is that there has been a layer of scar (capsule) that has formed around the fluid collection (similar to a bursa) This no matter how many times it is drained, or even a drainage tube placed, the fluid keeps returning.
The treatment for a encapsulated fluid collection is to remove the entire lining through a surgical procedure.(capsulectomy) as it is the lining that continues to produce the fluid. I don’t know what was done with the ‘cleaned and freshened’ part of your treatment and whether that involved the complete removal of this lining.
Once the lining is removed the decision then is whether a drain is placed to remove the immediate fluid that will occur or whether a en bloc fat graft should be placed. That would depend on thesis of the cavity.
The other option for treating encapsulated seromas is to inject sclerosing solutions. These exert their effect by internally ‘cauterizing’ the seroma lining to stop the fluid collection. My concern is your case with that approach is that it may cause reactive hyperpigmentation.
I would need to see a picture of the thigh area to give a better qualified answer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a transgender woman from Germany looking to get hip implants. I previously had FFS and, although not completely satisfied with the results, I no longer get misgendered. The only other area of concern for me is my hips and buttocks. Currently I wear hip/buttock padding daily and would like to be able to wear swimsuits/etc without worrying about my narrow hips and flat butt. I did not see any results on your site about this procedure however I did see answered questions. Thank you
A: Hip and buttock implants are different implants that have different effects. Custom hip implants can be made that extend partially into the buttocks but are not true buttock implants. Custom buttock implants can be made that extend partially into the hip but are not true hip implants. In some cases separate buttock and hip implants can be done together.
The key to your implant designs needed is the padding that you are wearing. If that is creating the desired effect then that would provide good guidance as to the type of implant design needed. Seeing pictures of your buttocks/hip area and the shape of the padding you use would be very helpful in that regard.
Dr. Barry Eppley
indianapolis, Indiana
Q: Dr. Eppley, I decided to have revision rhinoplasty here locally due to having young kids and no family close by even though we had such a great meeting. I just got my cast off and I am now regretting not going with my gut instinct. I had osteotomies done and while it’s very swollen and I am very bruised, when the cast came off it appears that my nose is deviating to the side now when it was straight before. I know swelling is common and I saw a 22 year plus board certified plastic surgeon, but I was not expecting this.
I will attach some photos. If this is cartilage shifting or needs a spreader graft is this something I need to wait 6-12 months for or if it needs resetting? I just can’t imagine waiting that long 🙁 I am not sure if it’s better to see you in person again?
I am so upset, and worried I have made a big mistake and will have to have to go through the cost and surgery again to have a optimal result.
Thank you again. Please excuse the bruising in the photos.
A: At just one week after surgery it would be impossible to really know what the nasal shape outcome will be. Swelling is almost never symmetric and you remain at the point of peak swelling and bruising. While I never like to see a deviated nose when the splint comes off, this does not always mean that the final result will be so. Regardless of how you may feel about it now, the wise course of action is to allow the healing process to play out for six months after the surgery. The tissues at this point are too inflamed to allow for any predictable manipulation even if one knew a revision rhinoplasty may eventually be needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In further discussion of getting a custom jaw implant is whether you also handled corrective jaw surgeries. I don’t know medical vernacular, but my dentist informed me that I should consider corrective jaw surgery. I don’t have an over/under bite, but rather a bite that resembles the “chattering teeth” toys, where my teeth more or less sit on top of one another. I thought if that is a procedure I need done, it would seem more cost effective, as well as better for my work schedule if both could be done simultaneously. Let me know your thoughts at your convenience, thanks.
A: As both a board certified plastic surgeon as well as an oral and maxillofacial surgeon, I have done many orthographic surgery procedures….but not many that incorporated a custom jaw implant at the same time. The key question as to whether that can be done or is even needed is whether the jaw correction would be done by a maxillary (LeFort 1 procedure) or a lower jaw moving procedure. (sagittal split) In an isolated LeFort 1 osteotomy, a lower jaw implant can be done. If the lower jaw is cut and moved then a lower jaw implant can not be done at the same time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a skull augmentation surgery for the back of my head as it’s very flat. I have a few questions:
1) Is this procedure dangerous? Have any of your patients had complications/died?
2) How many times have you done this/similar procedures? I have seen a video where you reshape the top of someone’s head, are there any additional videos/patient stories?
3) Why is this surgery so uncommon? I do not live in the Indianapolis area, but from my research, you’re one of the very few surgeons in the United States who does this procedure.
4) How long does the surgery take/the healing time? I read a few different responses online.
5) What is the estimated cost?
Thank you!
A: In answer to your questions about skull augmentation surgery, specifically occipital skull implant surgery, the answer to your questions are:
- Skull augmentation using custom made implants is a very safe and effective procedure. It is not more ‘dangerous’ than breast augmentation surgery. No major medical complications have ever occurred and none would be so predicted.
- I have performed over 150 custom skull implants and over 1,000 cranioplasies surgeries in general. Getting patients to be willing to tell their story online for all the world to see is very rare, particularly in aesthetic skull surgeries.
- I can not speak for what other surgeons do or don’t do. I only know what I do ink my plastic surgery practice.
- This is a 90 minute surgery procedure that 10 to 14 days to have a good recovery. There are no physical restrictions after surgery.
- My assistant will pass along the cost of the surgery to you tomorrow
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m writing about my sons head. When he was born he had a flat forehead and temples and his ears were aligned. At 4 months I noticed his forehead was slightly bulging forwards and I brought it up with my pediatrician who said the soft spot seems to have closed early. I asked should I get a helmet? He assured me a helmet won’t fix that and only surgery would. At the time I thought no, he isn’t getting surgery for a little bump. Over the next month I noticed his forehead started to bulge forwards much more and brought him to a cranial clinic for possibility of a helmet. They said it seems mild and it will go away as his forehead grows taller and flatten out. I was very happy to hear this. A month later I noticed the sides of his temples began to flair out and his forehead bulge forwards more. Frustrated I contacted the helmet clinic, they were shocked and said we can fit him in at ten months old but it’s probably too late. I am devastated by lack of care for my concerns initially. My sons head looks very very different from even eight weeks ago with the added bulging. The top of his head has expanded incredibly in width, there are large bumps and bony protrusions above his ears. His forehead is huge and his temples don’t sit back on the sides of his head any longer. They boss forwards into one large forehead and his ears stick right out now. I cry for him. I frequently get asked if he has a disability which hurts me. He is fine apart from his head, he is not disabled. He is 9 months old now and is just getting wider and worse. The bulges on the sides of his head are almost frightening. I know you are best in the world which is why I ask you for help.
I will attach photos of his head before and now.
I was wondering if you can change his life and do a cranial vault surgery to correct his skull to what it was before. He’s forehead and temples are now one. And there are large bumps on the sides of his head as well as a very protruding forehead.
Please help him.
A: The growth of the brain is what drives the early shape of the skull. It goes to areas of least resistance. Whether cranial vault surgery is an option would depend on numerous factors:
1) What does a 3D CT scan show in terms of his various skull plates and the sutures between them?
2) Would a neurosurgeon consider operating on a non-synostotic infant? Cranial vault surgery is done in conjunction with a neurosurgeon so theri willingness to do so is the key factor in undergoing the surgery.
3) Would insurance ever approve a non-synostotic cranial vault surgery? This would require #1 and #2 above as well as a predetermination letter to answer that question. This is not a surgery that can be done on an out of pocket basis, the costs are simply too high.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my flat head syndrome has been causing me great distress. I feel like an alien and don’t even think of myself as human. The condition is such that, I wake up thinking about it and fall asleep thinking about it. I no longer care about anything in life and everything seems so pointless to me now. I don’t know how I will carry on living with this condition. Please tell me that there is something that can be done cosmetically for this. Thanks.
A: The good news is that flat areas of the skull, the flat head syndrome, is highly improveable using custom skull implants made from a 3D CT scan. This is an aesthetic skull operation that I do regualarly. It is very likely that in a single 90 minute operation this is an issue you will be able to put behind you. The limits of skull augmentation are always based on how much the scalp can stretch to accommodate the implant. So the only question is whether a single stage procedure with an implant can achieve your skull augmentation shape increase goals. This is best determined before surgery by doing some computer imaging t see the difference between a one vs a two stage skull augmentation procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was wondering if skull reduction surgery makes a noticeable difference on the outside. I know the bone can be reduced on the inside but does that mean it also shows as much reduction on the outside?
A: Thank you for sending your pictures. Of all skull reduction areas the back of the head (occiput) is one of the most successful areas to reduce. Its thick bone allows for up to 7mms if bone reduction to be achieved from side to side. Based on your picture that is probably about what you need to bring the central areas of greatest projection back into a more average back of the head shape/profile. I always check before surgery a plain sideview skull film to determine how much of the outer cortical bone can be removed based on the bone’s thickness and the location of the diploic space. As a general rule the outer cortical layer of bone removal averages around 7mms until the diploid space is encountered. In more aggressive skull reduction the diploid space can be reduced down to the inner cortical layer but this is usually not done due to the bleeding that it causes as well as irregular surface it ca create.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, Can I have a custom jawline implant put while having a very long beard? Because I that I think it’s a pretty good camouflage, it may be helpful for the recovery procedure since it doesn’t really allow to see what the jaw looks like after surgery and prevents somebody from getting frustrated by the swelling appearance. Thank you in advance.
A: Thank you for your inquiry. Your suppositions about the beard as a postoperative camouflage are certainly valid. Also having a beard does not interfere with having the implant surgically placed. The only issue, and a very relevant one, is how would you or I know how to design the implant when we really don’t know how you look on the outside? What type of jawline change is visually desired? While the implant is designed on bone using a 3D CT scan, its dimensions are created by doing before computer imaging to see what type of lower facial change the patient is seeking. While having a beard for this surgery is acceptable I would advise a much closer cropped one so some preoperative guidance can be obtained about the implant design. That is how men do it for this surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question regarding a tummy tuck. I read of doctors over seas do it as regular with abdominal repair and their patients look a little more hour glass shaped. But I have not read many in America do it and the ones that said they do if requested don’t have before and after pictures of “oblique repair” I know that sutures are placed in the abdominal muscles usually in a tummy tuck and that does make the waist smaller and stomach slimmer. But can sutures be placed in the obliques as well and pulled in to give that really curve pinched drastic look like a corset does or close to it… basically changing the waist shape?
A: What you are referring to is the overall concept of fascial plication and not muscle repair. It is standard to almost always do midline rectus muscle fascial plication in a tummy tuck whose intent is to push back or flatten abdominal projection. This has no effect on horizontal waistline reduction. Fascial plication can also be done on the oblique abdominal muscles as well if the patient so desires. This can have some effect on waistline narrowing in the horizontal direction. The significance of its effect depends on the muscle/fascial laxity of the outer abdominal wall. There is nothing novel or unique about oblique fascial plication, it is just the additional use of sutures for maximum efforts at waistline shaping. But do not be under the misconception that it can have a corset-like effect as it can’t. Its effect will not be that substantial.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m thinking about getting cheek implants. I’m looking to get an angular high cheekbone look, as well as making the cheekbones wider. What kind of implant can achieve this? Also, how much can the cheekbones widen in mm? I realize a CT scan would be needed to be precise, but what is the average? Thank you.
A:Thank you for your inquiry. The high angular cheek augmentation effect is best achieved by what I call the ‘malar-arch’ cheek implant style or what is also known as the model cheek implant style. Such an implant is not a standard cheek implant and can be made in either a custom fashion from a 3D CT scan of the patient or from my own catalog of such custom cheek implants made for other patients known as special design cheek implants.
The amount of width in the cheek bone area that can be done is virtually unlimited and is based on the patient’s aesthetic desires. That being said the ‘average’ cheek width increase is in the 4 to 7mm range. But I have had patients who had their cheek and arch widths out to 10mm to 15mms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my malar fat pads has dropped away from my cheekbone on my right side significantly and to a lessor degree on the left side. I had a vial of Voluma injected which was just partially successful. I would like to know what procedure you prefer to elevate my pads? My goal is to not only lift the malar fat pad but at the same time make sure that the skin/tissue at the nasolabial fold is elevated. The most popular way seems to be sutures attached to malar fat pad and then pulled toward the temple where it is anchored. I am open to hearing what method you prefer to get the best results. I know you and I previously discussed the possibility of a more vertical lift to that area with an incision in the scalp and using sutures to elevate the midface area.
A: There are a variety of methods espoused for lifting the cheek soft tissues (cheeklifts) of which the temporal suspension approach is the most popular. In lifting the cheek tissues it is all about what direction (vector) to lift and where to suspend it. In reality the most effective approach is a purely vertical one done through the lower eyelid and attached directly upward vertically to the skull behind the hairline…this is also the most powerful cheeklift and one of my favorites as the downward drift of the cheek is vertically off the bone. It is very technically sensitive and requires some craniofacial experience which is why it is the rarest form done even if it is the most effective. The more limited version of this approach is to suspend the cheek tissues to the orbital rim through the lower eyelid incision. While popular the temporal suspension technique is not really the ideal direction (oblique vector) but is technically easier to perform. Regardless of the cheeklift technique used, its effects on the nasolabial folds are not profound and often short-lived.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had some questions about the cosmetic rib removal surgery procedure. And I would like to know if online consultations are free. If so, how can we schedule an online consultation ?
Also here are a few questions :
1. how is the recovery? I work a physical job, when would I be able to feel no pain when moving and when I press on my ribs ? How long?
2. I live out of the U.S.. Do I have to come accompanied with someone or can I come alone ? What’s is the aftercare like ?
3. How much does the surgery cost including aftercare and anesthesia, medications etc. ?
4. How often does pneumothorax happen ? What is the % of chance of it happening ? Is it relatively common or very rare ? (if the 10th is removed as well)
5. How often does chronic pain from the cut end of the rib happens ? What is the % of chance of it happening ? Is it relatively common or very rare ? If it happens how is it resolved? Is it a permanent chronic condition?
6. By how many inches is the waist typically reduced ? How significant or dramatic of a result can I expect ?
7. Can I see several before and after picture of actual patients? there’s no before/after picture of the rib removal procedure on your website
8. What are the long term risk or consequences that can happen afterwards?
9. Usually, does the procedure works out the first time or can it need a revision?
A: Thank you for your inquiry. In answer to your rib removal questions:
1) For a completely pain-free recovery this will take 3 to 4 weeks. You can go back to work anytime in the recovery you feel comfortable.
2) You may come alone for the surgery, this is common.
3) My assistant will pass along he cost of the surgery to you later today.
4) While pneumothorax is a known risk, I have never had it happen.
5) Chronic pain from the cut ends of the ribs has never been reported.
6) Most patients report a 1″ to 3″ reduction in their waistline.
7) Because of lack of actual visit followup, few patients are ever seen after the surgery for pictures. There is also the issue of patient confidentiality which must be respected.
8) I have never seen any long-term adverse consequences from rib removal surgery.
9) The procedure is a one time surgery. Whatever result you get the first time is the maximal result that can be obtained. There are no revisions that can be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to get augmentation of the brow ridge and lateral orbital rims. I have seen implants of yours which stretch from the brow bone to half way down the lateral orbital rim, but I am wondering can a single brow bone implant can be custom made to cover the entire lateral orbital rim up to the malar area.
Is it possible to create a custom browbone implant that also covers the entire lateral orbital rim down to the infraorbital rim? I have seen a few examples of brow bone implants of yours which stretch from the brow to halfway down the lateral rim. My lateral rims are recessed, and i was wondering if this can be accomplished as one piece implant?
A: Thank you for your inquiry. The simple answer to your question is that it can be. In custom designing facial implants any design can be made. The key in the design is the understanding of how it can be placed and to make sure that it can be placed as designed without undue scarring to do so. A custom brow bone implant can be made as one piece from one side of the lateral orbital rim to the other.
Dr. Barry Eppley
Indianapolis, Indiana
